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Musculoskeletal Flashcards

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1
Q

What is the majority of disease risk determined by in Ankylosing spondylitis

A

90% have HLA-B27

Male predominated

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2
Q

Describe the typical disease course for Ankylosing spondylitis

A

Before 30 years old

Insidious onset of lower back pain with spinal morning stiffness relieved by exercise

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3
Q

What are the 3 articular features of Ankylosing spondylitis

A

Inflammatory back pain:
Patients usually have morning stiffness and pain that starts in the sacroiliac joints and radiates to the buttocks. There is often tenderness of the sacroiliac joints. Advanced diseases sees the loss of lumbar lordosis and exaggeration of thoracic kyphosis with the neck stooped forward (Question mark posture).

Peripheral enthesitis:
Achilles tendonitis, Plantar fasciitis and tibial tuberosity. Painful in the morning - potential swelling

Peripheral arthritis:
Asymmetric joint involvement including - Hips, Shoulder, Chest wall, Pubic symphysis

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4
Q

What are the extra-articular features of Ankylosing spondylitis

A

Eyes - Acute anterior uveitis
CV - Aortitis to AR, Fibrosis to AV Block
Resp - Limited chest expansion to Restrictive, Fibrosis of upper lobes
Renal - IgA nephropathy
Neuro - 2o to fractures of fused spine - Cauda equina
Met - Osteopenia/Osteoporosis

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5
Q

What are the investigative results in Ankylosing spondylitis

A

Potential normocytic anaemia - FBC
Inflammatory markers may be elevated - ESR, CRP
Sacroiliitis or enthesitis/Spinal Osteopenia - XR
MRI - More sensitive
DEXA - Osteoporosis

Seronegative - -ve Rheuamtoid factor and ANA

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6
Q

What is Gout

A

Gout is a crystal arthropathy.

This is arthritis due to monosodium urate (MSU) crystal deposition within joints causing acute inflammation and tissue damage. These deposits are called Tophi

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7
Q

What joints are usually affected in Gout

A

Most of the time it is the MTP joint of the big toe (podagra)

Other joints:
Ankle,
Foot,
Small joints in hands,
Wrist, 
Elbow,
Knee

Potential to be polyarticular but is usually mono

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8
Q

What is the primary cause of Gout and what are the precipitating factors to this

A

The primary cause if hyperuricaemia usually due to inadequate excretion of uric acid from purine nucleotides

RFs: MALE
Dietary: Meat, Seafood, Alcohol, High triglycerides
Drug: Diuretics, Chemotherapy
Medical: Obesity, CHD, CKD, DM, HF, HTNm Psoriasis

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9
Q

What are long term complications of Gout

A

Urate deposits - Tophi

Renal disease - Stones, interstitial nephritis

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10
Q

What are the signs and symptoms of Gout

A

Swollen, tender, red joints - Peaks within 24hrs. Attack resolves in 5-15 days untreated.

Potential - Tenosynovitis, bursitis and cellulitis

Chronic tophaceous gout - Large deposits around extensors and ears

Crepitus and deformity

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11
Q

What are the investigative findings in gout

A

Negatively birefringent urate needle-shaped crystals and increased WCC - Polarised light microscopy of synovial fluid

High serum urate

Junta-Articular erosions - XR

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12
Q

What is Pseudo-gout

A

This calcium pyrophosphate deposition rather than monosodium urate and usually affecting larger joints

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13
Q

What is the presentation of Pseudo-gout

A

Acute monoarticular or oligoarticular arthritis.

Usually affects the knees

Often also wrists, shoulders, ankles, hands and feet. Almost any joint may be affected.

Presentation is similar (but usually milder) to acute gout, with acute joint pain and swelling.

Affected joints are acutely inflamed with swelling, effusion, warmth, tenderness and pain on movement.

Attacks may be associated with fever and raised white cell count.

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14
Q

What are the investigative findings in Pseudo-gout

A

Positive intracellular or extracellular birefringent rhomboid-shaped crystals - Polarised light microscopy of synovial fluid

Soft tissue calcium deposition - XR

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15
Q

What are the risk factors and associations of Fibromyalgia

A 
RFs
Female
Middle age
Low household income
Divorced
Low educational status

Chronic fatigue syndrome
IBS
Chronic headache syndrome

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16
Q

What are the main signs and symptoms of Fibromyalgia

A

Pain - Chronic (>3months) and widespread (Left and right, above and below diaphragm)

Fatigue - Profound with unrefreshing sleep and significant fatigue and pain with small increases in exertion.

Widespread and severe tender points

Other features:
Morning stiffness
Paraesthesiae
Headaches
Low mood
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17
Q

What are investigations in Fibromyalgia geared towards

A 
Exclusion of
Rheumatoid arthritis
Polymyalgia rheumatica
Vasculitis
Hyothyroidism
Myeloma
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18
Q

Who usually gets Giant cell arteritis

A

Temporal arteritis:
Woman older than 50
If they are younger then consider Takayasu’s.

It is associated with Polymyalgia rheumatica

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19
Q

What are the signs and symptoms of Giant cell arteritis

A

Headache
Temporal artery and scalp tenderness
Loss of vision

Malaise
Dyspnoea
Weight loss
Morning stiffness

Risk of irreversible bilateral vision loss

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20
Q

What are the normal investigative results in Giant cell arteritis

A 
Increased ESR and CRP
Thrombophilia
Increased ALP
Anaemia
Biopsy within 14 days of starting steroids - Beware of skip lesions
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21
Q

How is Giant cell arteritis treated

A

No visual symptoms - Oral Prednisolone

Visual symptoms - IV MethylPrednisolone

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22
Q

What are the symptoms of localised and generalised Osteoarthritis

A

Localised disease:
Hx Physically active
Pain and crepitus on movement
Pain is worse with prolonged activity.

Morning stiffness lasting under 30 minutes. (Longer than this may be suggestive of RA)

Joint instability can lead to perceived lack of power

Generalised disease:
Joint tenderness
Derangement and bony swelling (Heberden’s at DIP, Bouchard’s at PIP)
Reduced range of movement

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23
Q

Which joints are usually affected in localised and generalised Osteoarthritis

A

Localised:
Knee or Hip

Generalised:
DIP, PIP, CMC joints

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24
Q

What are the investigative findings in Osteoarthritis

A 
Plain XR
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

Potentially elevated CRP

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25
What are the risk factors for Carpal tunnel syndrome
Women Genetic: Short stature Fix Hereditary neuropathy ``` 2o: Obesity Colles fracture Trauma to wrist SOL in wrist DM Hyperthyroidism Menopause Inflammatory arthritides Acromegaly Renal dialysis Amyloidosis ``` Pregnancy
26
What are the characteristic features of Carpal tunnel syndrome
Aching pain in the hand and arms (especially at night), and paraesthesiae in thumb, index, and middle fingers: relieved by dangling the hand over the edge of the bed and shaking it (remember ‘wake and shake’). There may be sensory loss and weakness of abductor pollicis brevis ± wasting of the thenar eminence. Light touch, 2-point discrimination, and sweating may be impaired.
27
What are the investigative findings in Carpal tunnel syndrome
Tinnel's - Tapping lightly over the median nerve at the wrist causes a distal paraesthesia in the median nerve distribution. Phalens - Flexing the wrist for 60 seconds causes pain or paraesthesia in the median nerve distribution. ENG - The median nerve is stimulated proximal to the carpal ligament and compound muscle action potential is picked up over the thenar eminence. EMG - Useful but ENG better US - Confirming
28
What is Systemic sclerosis
A multisystem autoimmune disease characterised by functional and structural abnormalities of small blood vessel, fibrosis of skin and internal organs, and production of auto-antibodies
29
What are the antibodies involved in Systemic sclerosis
90% of cases are ANA positive 30-40% have anticentromere antibodies Limited: 70-80% Anticentromere antibodies Diffuse: 40% Antitopoisomerase-1 20% anti-RNA polymerase
30
What are the 2 main types of Systemic sclerosis and the main features of both
``` Diffuse Cutaneous Systemic Sclerosis (40%) Raynaud's phenomenon Followed by skin changes with truncal involvement Tendon friction Joint contracture Early lung disease Heart, GI and renal disease Nail-­‐fold capillary dilatation ``` ``` Limited Cutaneous Systemic Sclerosis (60%) CREST Syndrome Calcinosis Raynaud's phenomenon (O)esophageal dysmotility Sclerodactyly Telangiectasia ```
31
What are the signs and symptoms of Systemic sclerosis separated by system
Skin - Raynaud's disease Hands - Initially swollen and painful then later they thicken and tighten and become shiny. Changes in pigmentation and Finger ulcers Face - Microstomia - Puckering of skin around mouth. Telangiectasia Lungs - Fibrosis to hypertension Heart - Pericarditis or effusion, fibrosis, HF GI - Dry mouth, oesophageal dysmotility, GORD, Gastric paresis Kidneys - Hypertensive renal crisis, Chronic renal failure Neuromuscular - Trigeminal neuralgia, wasting and weakness Others - Hypothyroidism, impotence
32
Aside from the 1st line investigation of Systemic Sclerosis what other investigations can supplement the finding of ANA antibodies
``` Lungs - CXR, PFTs, CT Heart - ECG, Echo GI - Endoscopy, Barium studies Kidneys - U&Es, creatinine clearance Neuromuscular - EMG, biopsy Joints - Radiography ```
33
What is Systemic lupus erythematosus (SLE)
This is a multi-system inflammatory autoimmune disorder associated with tissue damage caused by vascular immune complex deposition
34
What are the presentations of SLE
``` General: Fever Fatigue Weight loss Lymphadenopathy Splenomegaly ``` Raynaud's Oral ulcers Skin rash - Malar/Discoid + Photosensitivity Systemic: MSK - Arthritis, tendonitis, myopathy Heart - Pericarditis, arrhythmias, Libman-Sacks endocarditis Lung - Pleurisy, effusion, atelectasis Neurological - Headache, stroke, cranial nerve palsies Psychiatric - Depression, psychosis Renal - Glomerulonephritis
35
What are the diagnostic criteria for SLE
SLE is an appropriate diagnosis when 4 or more criteria (at least 1 clinical and 1 lab) are met or biopsy-proven lupus nephritis with positive AN and anti-DNA ``` Clinical: Acute cutaneous lupus Chronic cutaneous lupus Non scarring alopecia Oral/nasal ulcers Synovitis Serositis - Lung or Pericardial Urinanalysis - Proteinuria or red cell casts Neurological features Haemolytic anaemia Leucopenia Thrombocytopenia ``` ``` Lab criteria ANA +ve 95% Anti-dsDNA Anti-Smith Abs Antiphospholipid Abs Low complement +ve Direct Coombs test ```
36
What is Cervical spondylosis
Progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs, and causing compression of the spinal cord and/or nerve roots
37
What are the common presentations of Cervical spondylosis
Neck: Neck stiffness ``` Pain: Arm (Stabbing or dull) Face Breast Chest ``` Legs: Weak and stiff legs Gait disturbances General: Paraesthesia Weakness Clumsiness
38
What are the signs of Cervical spondylosis
``` Arms: Atrophy of the forearm and hand muscles Segmental muscle weakness in a nerve root distribution Hyporeflexia Sensory loss Pseudoathetosis ``` ``` Legs - In cord compression Increased tone Weakness Hyper-reflexia Babinski +ve Reduced vibration and proprioception ```
39
What are the main investigations used in Cervical spondylosis
Cervical MRI - Bone destruction, Cord/ Nerve compression | Cervical XR - Degenerative joint, degenerative disc, fracture
40
What is Sjögren's syndrome
A chronic systemic inflammatory autoimmune disorder characterised by lymphatic infiltration into exocrine glands especially the lacrimal gland and salivary glands
41
What are the classifications for Sjögren's syndrome
It can be primary occurring alone or secondary occurring with another autoimmune inflammatory disease such as Rheumatoid arthritis, SLE or Systemic sclerosis (Scleroderma)
42
What are the main features of Sjögren's syndrome
Dry eyes Dry mouth Parotid swelling Dry URT - Dry cough Dry skin on hair Dry vagina Reduced GI mucus secretions - Reflux oesophagitis, gastritis, constipation General: Depression, weight loss, fever, fatigue
43
What are the main investigations for Sjögren's syndrome
Schrimer's test - A filter paper is placed in the lower conjunctival sac. The test is positive if less than 5 mm of paper is wetted after 5 minutes. Antibodies - Antibodies to the ribonucleoproteins 60 kD Ro and La are found in up to 90% of patients with Sjogren syndrome. Fluorescein/Rose Bengal Stains May show punctate or filamentary keratitis Other Investigations Reduced parotid salivary flow rate Reduced uptake or clearance on isotope scan Biopsy of salivary or labial glands
44
What is Septic arthritis
This is defined as infection of 1 or more joints caused by pathogenic inoculation of microbes.
45
What are risk factors for Septic arthritis
``` Increased age >80 DM Prior joint damage Joint surgery Prosthetic joints Skin infection in combination with joint prosthesis Immunodeficiency ```
46
What are the presenting symptoms and signs of Septic arthritis
Hot, Swollen, Painful joint(s) + Restriction of movement Fever + Rigors Knee most common site of infection
47
What are the main investigations necessary in Septic arthritis
Joint aspiration Blood cultures prior to antibiotics CRP/ESR/WCC - Elevated but not diagnostic
48
What are the important characteristics of Rheumatoid arthritis
It is a chronic systemic inflammatory disease Symmetrical, deforming, peripheral polyarthritis Increases risk of CVD (Maybe attributed to higher incidence in smokers) and is associated with HLA-DR1 & DR4 Potential extra-articular features
49
What are the typical and less typical presentations of Rheumatoid arthritis
Typical: Symmetrical swollen, painful, stiff small joints of hands and feet - Worse in the morning. Fluctuate and large joints may become involved. Possible presentations (No need to learn): Sudden onset widespread arthritis Recurring arthritis of various joints Persistent monoarthritis Systemic illness with extra-articular symptoms - Fatigue, fever, weight loss, pericarditis, pleurisy Polymyalgic onset - Vague limb girdle aches Reccurent soft tissue problems
50
What are the early and late signs of Rheumatoid arthritis
Early (Inflammation no damage): Swollen - MCP, PIP, Wrist or MTP joints. Reduction in range of motion Tenderness Later (Joint damage, and deformity): Ulnar deviation and subluxation of the wrist and fingers Boutonniere and swan-neck deformities of fingers or z-deformity of thumbs occur. Hand extensor tendons may rupture. Wasting of small hand muscles Palmar erythema Rheumatoid nodules - firm subcutaneous nodules Elbows, ulnar margin, palms and over extensor tendons
51
What are the main investigations need for Rheumatoid arthritis
Rheumatoid factor 60-70% XR - Deformity, Osteopaenia, Narrowing of joint space, Soft tissue swelling Anaemia of chronic disease ESR/CRP/Platelet - Elevated
52
What is Reactive arthritis
This is a sterile arthritis that occurs after an infection elsewhere in the body (GI or UG)
53
Who is usually affected by Reactive arthritis
Young men (20x more common) HLA-B27 associatino GI - Salmonella, shigella, yersinia, campylobacter UG - Chlamydia
54
What are the signs and symptoms of Reactive arthritis
Arthritis - Asymmetrical oligoarthritis - lower extremities - Sausage-shaped digits Conjunctivitis Urethritis - Burning or stinging when passing urine Sacroiliitis - Lower back pain Enthesitis - Painful heel ``` Oral ulceration Circinate balanitis Keratoderma Blennorrhagica Nail dystrophy Hyperkeratosis Onycholysis ``` Reiter's Triad: Conjunctivitis, urethritis, and arthritis
55
What are the investigative findings in Reactive arthritis
ESR/CRP - Elevated XR - Sacroiliitis and enthesitis HLA-B27
56
What is Osteomyelitis
Infection of the bone leading to inflammation, necrosis and new bone formation Staph A Group A Strep
57
Who is affected by Osteomyelitis
Young children Trauma Operative Ulcers ``` DM Immunosuppression IVD Prosthesis Sickle-cell anaemia ```
58
What are the signs and symptoms of Osteomyelitis
``` Pain Fever + Rigors, Malaise Erythema Tenderness Swelling Warmth Limited movement Seropurulent discharge ```
59
What are the investigative findings in Osteomyelitis
ESR/CRP/WCC - Raised | XR - Acute disease - Osteopenia appears 6-7 days after infection onset
60
What is Polymyalgia rheumatica
Inflammatory condition characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle. Associated with GCA
61
What are the common signs and symptoms of Polymyalgia rheumatica
Limb girdle stiffness and pain Morning stiffness of greater than 45 minutes Symptoms worse when waking Low-grade fever + other flu like features
62
What are the appropriate investigations for Polymyalgia rheumatica
ESR/CRP - Elevated | US - Bursitis/Joint effusion
63
What is the treatment of Polymyalgia rheumatica
Coricosteriods - Oral Prednisolone 15mg/day generally response should be very quick Monitor for adverse effects of steroids Methotrexate may be considered for patients with prolonged therapy
64
What are Idiopathic inflammatory myopathies 
A heterogenous group of skeletal muscle that have in common - Proximal muscle weakness and inflammation on muscle biopsy Polymyositis Dermatomyositis
65
What are causes of the Idiopathic inflammatory myopathies 
They are both autoimmune diseases with viral infection being implicated
66
Who is usually affected by the Idiopathic inflammatory myopathies 
Polymyositis - 30-60 Dermatomyositis - Any age (Biphasic) Both are more common in women
67
What are the signs and symptoms of Polymyositis
Bilateral proximal muscle weakness, wasting and myalgia If the muscles of the pharynx or oesophagus are involved then this can lead to dysphonia and dysphagia
68
What are the signs and symptoms of Dermatomyositis
Bilateral proximal muscle weakness, wasting and myalgia If the muscles of the pharynx or oesophagus are involved then this can lead to dysphonia and dysphagia Rash: - Purplish rash on upper eyelid with oedema (Heliotrope) - Rash around the whole upper girdle (Shawl rash) - Facial rash - Gottron's papules (Red scaly rash on knuckles and elbows) - Nail fold changes
69
How is Polymyositis diagnosed
Definitive diagnosis: Muscle Biopsy - Endomysial inflammatory infiltrates, Muscle necrosis, atrophy, muscle fibre regeneration Creatine kinase - Up to 50x normal EMG - Reduced activity Antibodies: ANA, Anti-Mi-2, Anti-SRP, Anti-Jo-1 Myoglobin - Useful for disease severity Enzymes less specific than CK: Aldolase, LDH, ALT
70
How is Dermatomyositis diagnosed
Definitive diagnosis: Muscle Biopsy - Perifascicular atrophy, Perivascular/Perimysial inflammation ``` Creatine Kinase - Not as useful in Poly EMG - Reduced activity Antibodies: ANA, Anti-Mi-2, Anti-Jo-1 HLA-DR3/5 Association Myoglobin - Useful for disease severity ``` Enzymes less specific than CK: Aldolase, LDH, ALT
71
What are Vasculitides
These are inflammatory disorders of blood vessels It may be primary or secondary to another disease: SLE, RA, HEPB/C, HIV.
72
How are Vasculitides classed?
By the type of vessel they affect Large: Giant cell arteritis, Takayasu's arteritis Medium: Polyarteritis nodosa Small: Microscopic polyangiitis, Eosinophilic granulomatosis with polyangiitis (Churg Strauss Syndrome), Granulomatosis with polyangiitis (Wegener's Granulomatosis), All: Behçet’s disease
73
Outline Takayasu's arteritis
What: Aorta and it's major branches Epi: Young women (Asian) Signs and symptoms: - Turbulent blood flow leading to bruits (Potentially in all major arteries) - Blood pressure asymmetry - Reduced or absent peripheral pulses - Limb claudication - FLAWS Diagnosis: - CT Angio/MRA showing skip lesions
74
Outline Polyarteritis nodosa
What: Skin, Renal and mesenteric Epi: Hep B individuals - Rosary sign on renal angiogram Signs and symptoms: - Joint & Muscle pain - Skin rash - Livedo reticularis - Palpable purpura - Peripheral neuropathy - GI bleeding - Renal failure - HTN + MI Diagnosis: - Angiography - Cluster or small aneurysms - Biopsy (Skin, Blood vessels, nerve, muscles...)
75
Outline Microscopic polyangiitis
What: Non-granulamatous inflammation in blood vessel of: Eyes, Larynx, Lungs and Kidneys Epi: Middle Ages Signs and symptoms: Similar signs and symptoms to Wegener's but more of the glomerulonephritis aspects Diagnosis: - pANCA - Biopsy of affected organ (Skin, Kidney or Lung)
76
Outline Eosinophilic granulomatosis with polyangiitis (Churg Strauss Syndrome)
What: Granulamatous inflammation with Eosinophilia in blood vessel of: Eyes, Larynx, Lungs and Kidneys Epi: Hx Atopy ``` Signs and symptoms: Similar signs and symptoms to Wegener's but with Allergic symptoms beforehand - Asthma - Chronic rhinosinusitis - Blood Eosinophilia - Peripheral neuropathy ``` Diagnosis: - pANCA - ECG - Echo
77
Outline Granulomatosis with polyangiitis (Wegener's Granulomatosis)
What: Granulamatous inflammation in blood vessel of: Eyes, Ears, Nose, Larynx, Lungs and Kidneys Epi: White Signs and symptoms: - Eyes - Painful exophthalmos, Diplopia, Optic nerve ischaemia, Sceritis or Uveitis - Ear - Otitis, Deafness - Nose - Saddle nose deformity, Recurrent sinusitis - Larynx - Hoarse voice, Collapse - Lung - Nodules (Biopsied) - Renal - Glomerulonephritis, KF Diagnosis: - cANCA - Biopsy of affected organ (Skin, Kidney or Lung)
78
Outline Behçet’s disease
What: Affects all vessels Epi: Greek, Turkish, HLA- Signs and symptoms: - Recurrent oral ulcers (Larger, more painful, and longer to heal than Aphthous ulcers) - Almost continuously present - Genital ulcers - Anterior Uveitis - Sterile pus (Hypopyon), Painful, Redness - Posterior Uveitis - Painless, floaters, decreased vision - Folliculitis - Erythema nodosum - Arthritis - Colitis Diagnosis: - Clinical based on symptoms - Pathergy test - Pin prick becomes an ulcer after 2 days

All conditions - Year 3 (16 decks)

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